A senior care home nurse at Paternoster Care Home has been cautioned by the Nursing and Midwifery Council (NMC) after failing to call 999 to report an unresponsive resident.
The unnamed patient at the care home had a number of health conditions linked to her old age, but was not given a Do Not Resuscitate order and therefore should have received prompt medical attention.
Paulina Abiade, the nurse in charge of the home, was told that the elderly woman was unresponsive at 08:40 and needed prompt medical attention, reports the Gloucestershire Echo.
But instead of phoning 999 and summoning a paramedic, Ms Abiade tried to call the resident's husband, who was a regular visitor and lived just down the road from the facility.
The man did not answer any of the calls made to him, as he was out running errands at the time.
However, despite this Ms Abiade failed to phone the emergency services and persisted in her attempts to contact the woman's husband before finally managing to do so by 12:00.
When the man came around to the nursing home, he advised the nurse to phone 999, but despite the efforts of paramedics who rushed to the scene, she died at around 13:00.
While it is not clear if the woman would have survived if she had received more prompt medical attention, Ms Abiade was summoned to a NMC tribunal hearing where she was charged with misconduct.
The nurse admitted she should have implemented a policy that dictated an ambulance should be called if a patient deteriorates in the manner that the woman did in this case.
However, she was not barred from practicing, as Stephen Barker, chairman of the NMC's tribunal panel, ruled that in her many years of practice this was the first serious error she had made.
"The panel noted that you deeply regret your omission, you apologised to this panel unreservedly and you have demonstrated remorse," Mr Barker said.
By Francesca Witney